Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 1
A SIMPLE APPROACH TO 12 LEAD ECG INTERPRETATION
Nicole Kupchik RN, MN, CCNS, CCRN, PCCN
Objectives
Discuss the changes reflected on the 12 Lead ECG with ischemia, injury & infarction
Review the anatomy of a 12 Lead ECG
Discuss signs and symptoms associated with inferior, right ventricular & anterior/septal wall myocardial infarctions
Differentiate left vs. right BBB
Discuss emergent pacing indications, set-up, settings & issues with pacing
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 2
Some thoughts on the 12 Lead ECG…
It is not the “silver bullet” diagnostic
It gives you a “picture” at a moment in time
For ongoing ischemia, you should perform serial 12 Lead ECGs for comparison
The standard 12 Lead ECG does not examine the right ventricle or posterior walls
Poorly examines the lateral wall
Conduction Review
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SA Node “Sinus Node”
Dominant pacemaker (60-100 bpm)
Depolarization flows away from the SA node in many directions
Intrinsic rate
AV Node “Atrio-ventricular”
The only conducting pathway between the atria & ventricles
AV valves electrically insulate the ventricles from the atria
Impulses are sent to the AV node - slowed
Produces the “PR” interval
Atria contract
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 4
Ventricular conduction
Bundle of His (40-60 bpm)
Left & Right Bundle Branch
Purkinje Fibers (20-40 bpm)
Bedside ECG Monitoring
5 Lead system
Lead V1 best for:
Bundle Branch Blocks
Ventricular dysrhythmias
Limb leads below the rib cage
V1 – 4th ICS
White Black
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ECG Lead Placement
4 limb leads
6 chest leads
Views from 2 different planes:
- Frontal (coronal)
- Horizontal (transverse)
12 different angles
RA LA
LL
Lead I_ +_
++
_
Standard Limb Leads (Bipolar Leads)Leads I, II, III
Lead I Left arm positive Right arm negative
Lead II Left leg positive Right arm negative
Lead III Left leg positive Left arm negative
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 6
RA LA
LL
+
+
+
Augmented Limb Leads (Unipolar Leads)aVR, aVL, aVF
Reference point in center of chest – “telephoto lens”
aVR Right arm positive
aVL Left arm positive
aVF “Foot” (left leg) positive
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 7
Precordial Leads
Normal 12 Lead ECG
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 8
ST Segment
ST elevation: Injury ST elevation ≥ 1mm (limb leads) or ≥ 2 mm (precordial leads) and/or
new Left BBB 2 or more contiguous leads Contiguous: Leads that look at the same
anatomical area of the heart
ST depression: Ischemia or T wave inversion
Q-waves
Considered pathologic if:
Width > 30 ms (≥ 0.04)
Width ≥ 25% of the height of the R wave
If present in contiguous leads, indicative of myocardial necrosis
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 9
Q waves – myocardial necrosis
May or may not be present
12 Lead ECG Review
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 10
12 Lead Review
12 Lead ECG Review
Location Change in lead:
Reciprocal changes in lead:(ST Depression)
Artery affected:
Notes:
Inferior II, III, aVF I, aVL RCA in 65%L circumflex
Right sided ECG assess V2R-V4R
Septal V1 - V2 II, III, aVF LAD
Anterior V3 - V4 II, III, aVF LAD/L main
Lateral I, aVL, V5 - V6 L circumflexLAD
Posterior Posterior leads V7 - 9
V1 - 3 L circumflexRCA
Tall upright R wave in V1 – V3
Right ventricle
V1 orV2R-V4R
Proximal RCA
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 11
Coronary Artery Perfusion
Inferior Wall
Lateral Wall
Septal & Anterior
Wall
Posterior Wall
12 Lead ECG Practice
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What’s your interpretation???
What’s your interpretation???
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 13
What’s your interpretation???
What’s your interpretation???
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 14
Anything else look different?
67 yo female, L vent systolic dysfunction, c/o CP, N/V, diaphoresis, blurred vision. On diuretics, ACE Inhibitor, Imdur. S/P 3V CABG. EF 23%
What’s your interpretation???
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 15
What’s your interpretation???
@ 7:26 am
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 16
STEMI
ST elevation ≥1mm (inferior) or ≥2 mm (anterior) and/or new Left BBB
*Hallmark signs* Chest pain > 20min.SOB, diaphoresis
+ Cardiac biomarkers Complete occlusion Treatment:
Aspirin Nitroglycerin 0.4 mg SL x 3 Reperfusion - PCI or fibrinolytics
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Case #1
64 y.o. male patient is admitted to the ICU s/p resuscitation from a primary ventricular fibrillation arrest
Mechanically vented & receiving cooling therapy post arrest
Temperature 33.6˚C
VS: HR 80s, BP 90-100s/50s-60s, O2 sat 95%
12 Lead ECG 3 hours post arrest
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 18
Case #1 continued…
64 y.o. male patient is admitted to the ICU s/p resuscitation from a primary ventricular fibrillation arrest.
Vented & receiving cooling therapy post arrest
VS: HR 80s, BP 90-100s/50s-60s MAP ~65, O2
sat 95%
Monitor starts alarming and you notice a change in rhythm and appearance of the QRS complexes
Repeat 12 Lead ECG
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 19
Case #1 Knowledge √
Interpretation of the 12 Lead ECG:
A. Acute Inferior wall MI
B. Acute Lateral wall MI
C. Acute Posterior wall MI
D. Acute Anterior wall MI
Case #1 Knowledge √
The rhythm change is: A. Complete Heart Block B. First Degree AV Block C. Second Degree Type 1 (Mobitz I) D. Second Degree Type 2 (Mobitz II)
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 20
Inferior wall MI symptoms
Wenckebach/Second Degree Type I
• Bradycardia• AV heart blocks – 1st degree, 2nd degree Type 1
May need temporary pacer• Hypotension• N/V• Diaphoresis
Occurs high in the AV nodeLengthening PR intervalRarely progresses to CHB
Inferior wall MI
Changes noted in Leads II, III & AVF
If suspected RCA occlusion- Lead III preferred
Reciprocal changes in Leads I & AVL
Monitor for RV failure Tachycardia Hypotension
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 21
Case #1 Knowledge √
What would be the most appropriate action at this time?
A. Start Nitroglycerin infusion to promote coronary vessel vasodilation
B. Start rTPA as quickly as possible C. Activate a Code Blue response and start chest
compressions D. Ensure the patient has received aspirin, notify
the Cardiologist & activate the cardiac cath lab
Case #1 Knowledge √
Patient was in the cardiac cath lab in < 20 minutes
The patient received a stent to the:
A. Left anterior descending
B. Posterior descending
C. Marginal artery
D. Right coronary artery
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 22
Case #1 Knowledge √
The patient returns to the ICU & cooling is continued for a total of 24 hours. He wakes up the next evening & follows commands. VSS.
Which of the following medications should be anticipated at discharge?
A. Aspirin, Plavix, Statin, Beta blocker, ACE Inhibitor
B. Plavix, Angiotensin Receptor Blocker & CaCh Bl.
C. Aspirin, diuretics & beta blockers
D. Aspirin, Plavix & Calcium Channel Blockers
Case #2
46 year old female is admitted to your unit with c/o nausea, diaphoresis, back discomfort, & fatigue.
Initial troponin is 1.3 ng/mL
Initial 12 Lead ECG is “unremarkable”
She receives aspirin 325 mg PO, Metoprolol 25 mg PO, Mylanta
VS: HR 72, BP 106/52 (70), RR 18, T 37.1 C, O2
sat 97%
Now c/o discomfort, you get a 12 Lead ECG
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 23
12 Lead ECG
Right sided ECG
Key leads are V2R – V4R
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 24
Right sided ECG V2R – V4R
Case #2 Knowledge √
Clinical signs of a worsening right ventricular infarction include:
A. Bradycardia, hypotension & nausea/vomiting
B. Bradycardia, S4 heart sound & hypotension
C. Tachycardia, + JVD & hypotension
D. Tachycardia, S3 heart sound & hypotension
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 25
Case #2 Knowledge √
The cardiac cath lab has been activated. Repeat VS: HR 122, BP 88/46 (60), RR 22, O2 sat 96%
Priorities for this patient include: A. IV fluid bolus B. Dobutamine infusion C. Lasix 40 mg IV D. Nitroglycerin (Tridil) infusion
Case #2 Knowledge √
Which medication should be avoided in a patient with a right ventricular infarction?
A. IV fluids
B. Dobutamine
C. Nitroglycerin
D. Aspirin & Plavix
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 26
Right Ventricular Infarction
Associated with Proximal RCA occlusion & inferior wall MISymptoms: Tachycardia Hypotension + JVD (with clear lungs)Treatment: **IV fluids** + Inotrope or IABP Avoid medications that lower preload: Nitrates Morphine Beta Blockers
Signs of right sided heart failure:
Jugular venous distention Tricuspid regurg ↑Central venous pressure Hepatojugular reflux Peripheral edema Hepatomegaly Anorexia, N/V Ascites ↑Liver enzymes
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 27
Case #3 - 76 year old male
Admitted to your unit after c/o chest pain during a colonoscopy.
PMH: HTN, Type 2 DM, PVD, MI with stent to RCA 3 yrsago. Meds: BB, ACE-I, statin, ASA
Currently c/o SOB & mid-sternal chest discomfort. He also has GI/epigastric pressure that was not relieved with an antacid.
He now rates the pressure 6/10.
What would you like to do next?
Results of 12 Lead ECG
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 28
Case #3 Knowledge √
This 12 Lead ECG is consistent with:
A. Acute anterior wall MI B. Acute inferior wall MI C. ST segment depression & + enzymes = NSTEMI D. Normal ECG
Case #3 continued
Troponin level is: 3.2 NSTEMI He is complaining of
worsening SOBRepeat VS: HR 108 BP 94/46 (58) RR 28 O2 sat 91% S3 heart sound,
crackles bilaterally
Should he go to the cathlab?
TIMI Risk Score
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 29
Case #3 continued
Which discharge meds do you anticipate the patient will be prescribed?
Aspirin
Plavix, Effient or Brilinta
Beta blocker
Statin
Possibly long acting nitrate
ACE Inhibitor
Case #4
46 year old female Type 1 diabetic presents with c/o shortness of breath.
On physical exam is diaphoretic, with S3 heart sounds and poor capillary refill. Extremities appear dusky.
Labs have been sent (chem panel, CBC, troponins, HgbA1C, coags)
Called for portable chest x-ray
VS: HR 122, BP 94/46 (62), RR 32, O2 sat 90%
You hear audible crackles
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 30
Stat portable CXR
Case #4 12 Lead ECG
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 31
Case #4 Knowledge √
This patient is experiencing an acute:
A. Inferior/Right ventricular wall MI
B. Inferior/Lateral wall MI
C. Inferior/Posterior wall MI
D. Anterolateral wall MI
Anterior/Septal MI
Changes noted in V1 - V4 Reciprocal changes in II, III, AVF Loss of R wave progression Culprit vessel: LAD/Left main Symptoms:
Left ventricular failure, shockMonitor for: Heart failure Heart block (2nd degree Type 2,
CHB) Bundle branch block loud murmur suspect
ventricular septal rupture
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 32
Anterior Wall ECG changes
Second degree type II AV block
-Occurs below the AV node-Can progress to CHB-Constant PR interval-2:1 difficult to diagnose-Place a trancutaneous pacer-Prepare for transvenous pacer
Complete heart block/Third degree AV Block
_____________________________________________________________________
-No atrial impulses pass through the AV node-Ventricles generate their own rhythm
Case #4 next steps…
Cardiac catheterization lab activated
Furosemide 40 mg IV administered
Aspirin
VS: HR 90, BP 96/54 (68), RR 32, O2 sat 90%
Stent placed to the:
Left main!!!
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 33
Case #5
Inferior/posterior MI – perform posterior ECG
Case #5 Knowledge √
The results of the 12 Lead ECG reveal:
A. Anterior wall infarction
B. Lateral wall infarction
C. Inferior wall infarction
D. Posterior wall infarction
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 34
Case #5 Knowledge √
Which vessel is likely the culprit?
A. Left anterior descending
B. Right coronary artery
C. Marginal artery
D. Circumflex artery
Posterior ECG
Assess posterior leads V7 – V9
for ST elevation
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 35
Posterior
Changes in V1-V2
Tall, broad R wave (>0.04) & ST depression (reciprocal change)
Posterior leads V7 - V9
Associated with inferior/lateral wall MI
Occlusion of RCA or left circumflex
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 36
OTHER INTERESTING CASES IN ACUTE CORONARY SYNDROME
ECG Practice
Case #6
Patient presents c/o stabbing chest pain that is worse with inspiration. The pain is better when they sit up & lean forward.
Had a MI 2 weeks ago, this pain started 3 days ago.
Ibuprofen is the only medication that decreased the pain level.
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 37
What’s your interpretation?
Case #6 Knowledge √
This patient is likely experiencing:
A. Acute anterior wall MI
B. Acute pericarditis
C. Acute lateral wall MI
D. Acute decompensated heart failure
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 38
Pericarditis
Inflammation of the pericardial sac Acute or chronic Chest pain – sharp, stabbing, or dull & achy
Pain improved when sit-up, lean forward Left sided radiation Pain worse with cough, positional changes & inspiration
Pericardial friction rub Treatment:
NSAIDS – high dose Ibuprofen Antibiotic if bacterial, antifungal if fungus
Case #7
59 y.o. male presents to the ED with “palpitations” and severe mid-sternal chest pain
PMH: HTN, Chronic renal insufficiency, drug abuse
Currently rates pain 10/10
12 Lead ECG
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 39
Initial 12 Lead ECG Case #7
Case #7 continued…
What would you like to do?
Activated the cardiac cath lab
Aspirin 325 mg PO
Nitroglycerin 0.4 mg SL q 5 min x3
Beta blocker?
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 40
Case #7 continued
Chest compressions started
Defibrillated with 200 joules
Continued the cath & his coronaries were “clean”
Severe vasospasm of the RCA
Intra-coronary NTG
Started on Calcium channel blocker
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Intra-Coronary Nitroglycerin
What looks different?
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 42
58 year old missed dialysisK+ 8.2
On dialysis – K+ 6.1
Case studies in ACS & 12 Lead ECGs www.nicolekupchikconsulting.com 43
Bundle Branch Blocks
Left or right BBB?
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